1

TITLE:

Incidence, prevalence and mortality trends in chronic obstructive pulmonary

disease over 2001 to 2011: A public health point of view of the burden.

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SHORT TITLE:

Burden of COPD a public health point of view

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AUTHORS: Marive Doucet PhD1,2, Louis Rochette MSc1, Denis Hamel MSc1

FROM:

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1. Institut National de sant publique du Qubec, Quebec, Canada

2. Deparment of Medecine, Laval University, Quebec, Canada

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WORD COUNT:

3028 (manuscript); 250(abstract)

NUMBER OF TABLES:

14

NUMBER OF FIGURES: 15

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CORRESPONDENCE TO:

Marive Doucet

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Institut national de sant publique du Qubec

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945, avenue Wolfe

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Qubec, QC

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G1V 5B3

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E-mail:marieve.doucet@gmail.com

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Doucet et al.
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ABSTRACT

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Background: In the last decade, an increase of overall chronic obstructive pulmonary

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disease (COPD) prevalence was reported in Canada despite the decline of the main risk

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factor and mortality. Objectives: 1) Estimate in 2001 to 2011, incidence, prevalence and

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mortality of COPD among 35 years and older using Quebec health administrative data.

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In order to establish the COPD burden 2) evaluate the effects of age-period-cohort on

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incidence trends, 3) and describe the prevalence of seven comorbidities. Methods: A

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retrospective population-based cohort was built using health administrative data. The

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overall change of the prevalence trend was measured by relative percentage of changes

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and the identification of potential variation in the trend of incidence and all-cause

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mortality was performed by a Joinpoint regression. After a descriptive analysis of the

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trends, an age-period-cohort analysis was performed on incidence rates. Results:

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Overall increase in prevalence along with a decrease of incidence and all-cause

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mortality was observed. Over time, all age-standardized trends were higher in men

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compared to women. Despite higher rates, the number of incident and prevalent cases

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in women exceeds men since 2004. The curves analysis by age-groups showed

Doucet et al.
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overtime a downshift for both sexes in incidence and all-cause mortality. However, this

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downshift was more marked in incidence. Further analysis on incidence trends showed

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the presence of a cohort effect in younger women. Conclusion: The burden of COPD

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has risen over time and was mostly borne by women. Women younger than 65 years old

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has identified as at risk group for healthcare planning.

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KEYWORDS: chronic obstructive pulmonary disease, burden, public health, health

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administrative data

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Doucet et al.
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Introduction

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Chronic obstructive pulmonary disease (COPD) is a progressive disease associated with

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successive exacerbation episodes that lead to frequent hospitalization (1). Furthermore,

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this respiratory disease is frequently associated with comorbid conditions that make

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COPD, a disease with heavier clinical management (2, 3). Effort to estimate adequately

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the COPD burden was made internationally, the population-based study, Burden of

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Obstructive Pulmonary Disease (BOLD), has challenged previous results reported by

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population-based survey that obtained lower prevalence estimate with self-report

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diagnosis (4, 5). This international study, based on self-report and measured data, has

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reported a prevalence of 10.1% in moderate to severe COPD worldwide (GOLD II or

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higher) (4).

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The Canadian initiative of BOLD, the COLD study, has estimated that COPD afflicts

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more than 15.0% of Canadian in early stage (GOLD I or higher) and 7.9% in GOLD II or

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higher (6). Another Canadian population-based study has instead used health

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administrative data to estimate the COPD burden, and has observed an overall

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prevalence of 9.5% (7). The same study, has reported a substantial increase of the

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prevalence along with a decrease of incidence and all-cause mortally trends (7).

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This raise of overall COPD prevalence is interesting despite over 30 years of cigarette

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smoking prevalence declined, in addition to a mark decrease of mortality over the last

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decade. The link between incidence, prevalence and mortality in COPD needs to be

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exploring in order to draw a proper picture of its burden.

Doucet et al.
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In the province of Quebec, the second province in population importance in Canada, a

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surveillance system of chronic diseases based on an access to a linked health

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administrative database was used to estimate the burden of COPD (8, 9).

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The main objective of this study was to estimate for the period of 2001 to 2011,

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incidence, prevalence and mortality of COPD individuals among 35 years and older

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using Quebec health administrative data.

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Furthermore, this study will: 1) estimate the overall trends in term of sex and age groups

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as well as identify years with potential variation in the trend. In a second step this study

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will focus on the understanding of the prevalence trend in order to draw a proper picture

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of the COPD burden and: 2) explore the potential effects of age, period or cohort effect

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on incidence trends, 3) describe in COPD population, the prevalence of seven main

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comorbidities that are identified for public health surveillance.

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Doucet et al.
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METHODS

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Study Population

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A retrospective population-based cohort was built using linked health administrative data

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used for surveillance of chronic diseases in Quebec (8). This system represents almost

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the entire population of Quebec and includes: 1) the health insurance registry of the

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Rgie de lassurance-maladie du Qubec that contains sociodemographic informations

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for nearly all of population of Quebec, 2) fee-for-service data (physician billing), 3)

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hospital discharge as well as 4) drug data for the 65 years and older and 5) mortality

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data. The present study covers all residents insured with the Quebec universal health

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insurance plan recorded in the RAMQ database, from January 1st 1996 to March 31st

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2012.

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COPD cohort:

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Identification of diagnosed COPD case was defined as at least one visit to a physician,

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OR one hospitalization with a diagnosis of COPD from all available diagnostic fields,

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among individuals 35 years or older. COPD diagnoses were identified through ICD-9

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codes 491-492, 496 or ICD-10-CA J41-44. This validated definition case was associated

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with a sensitivity of 85% (95% CI: 77.0% to 91.0%) and a specificity of 78.4% (95% CI:

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73.6% to 82.7%) (10).

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A run-in period of five years was necessary (7), therefore this study covered the period

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of April 1st 2001 to March 31st 2012.

Doucet et al.
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Indicators

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Incidence Rate: The number of new annual cases of COPD divided by the at risk

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population.

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Prevalence: The number of diagnosed cases of COPD divided by population.

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Prevalence of comorbidities: Prevalence of comorbidities measured in individuals with

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and without COPD will be presented by sexes for the period 2011-12. Prevalence ratios

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of COPD on individuals without COPD will express excess of chronic diseases in COPD.

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Comorbidities measures represent prevalent chronic diseases (8, 11) that have been

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reported to be associated with COPD (2, 12) (Table 1).

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All-cause mortality Rate: The number of deaths due to any cause according to case

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status, with or without COPD, divided by the population.

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Statistical analysis

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All rates and rate ratios were age-standardized to 2001 Quebec population. The

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standardization procedure was done using the usual direct method.

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Trend analysis

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The overall change of the prevalence trend was measured by the relative percentage of

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changes. This method calculates the percentage of changes between the rates of two

Doucet et al.
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fiscal years using as the reference the rate of the earlier year, ([TFinal TInital] /

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TInitial) x 100.

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Identification in the trend variation of incidence and all-cause mortality was performed by

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a regression analysis developed by the National Cancer Institute for trend analysis (13).

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Joinpoint

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http://surveillance.cancer.gov/joinpoint/) that uses several different segments that are

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connected together at the joinpoints, takes trend data and fits the simplest joinpoint

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model that the data allow. The annual percentage of change (APC) in rates with 95%

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CIs is provided for each segment between 2 joinpoints, and a permutation test was

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used to select the model that best fitted the data.

Regression

is

software

(version

4.0.4

May

2013

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In addition, a statistical test for comparing age-standardized rates (14) was used to

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compare men with women in different age groups of age-specific incidence and in all-

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cause mortality for 2001 and 2011. The same method of comparisons was employed in

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the prevalence of each comorbidity and to identify significant differences between sexes

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in rate ratios.

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Age-period-cohort analysis

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This model considers three factors in the analysis (15). The age factor that is associated

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to the physiological change in individual (15). The period time factor, which represents

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an external influence (15), such as a new governmental policy on smoking restriction in

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public site. This factor influences almost all individuals at the same time. The birth cohort
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Doucet et al.
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factor, affect all individuals that are born within the same years (15), such as smoking

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habit in a generation.

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To evaluate the effects of these interconnected variables, four periods of three years

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that extend from 2000-02 to 2009-11 were grouped together in 17 age groups (35-37 to

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83-85) for 17 birth cohorts from 1922-24 to 1970-72.

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A multiphase approach combining graphical inspection followed by the median polish

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method (second-order effects are estimated and interpreted) and the Holford method

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(first order effects estimated with a second-order effects interpreted) (16, 17).

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Doucet et al.
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RESULTS

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COPD Cohort

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Based on the definition case used, 444,709 (males: 212,270, females: 232,432)

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individuals over 35 years old were identified with COPD in the province of Quebec, in

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2011-12.

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Incidence

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In all diagnosed COPD aged of 35 years and older, the number of newly diagnosed

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cases decreased from 2001 to 2011 (44,400 to 31,318) and this was true in men (22,107

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to 15,363) and in women (22,293 to 15,955), Figure 1 A.

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Over the period, age-standardized COPD incidence rates decreased from 12.0 to 6.9

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per 1000, Figure 1 B. This observation was seen in both sexes, Table 2.

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The incidence rate of individuals with COPD rose with increasing age. In 2011, the age-

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specific incidence rates were higher in men than women beyond 65 years old (p 0.01).

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In contrast to 2011, the difference between sexes arrived at a younger age in 2001 (55

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years and older, men compared to women, p 0.01), Figure 1 C.

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170

Prevalence

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The number of prevalent cases increased from 2001 (men: 163,128; women: 160,652)

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to 2011 (men: 212,270; women: 232,432) (figure 2 A) with an age-standardized

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prevalence that rose from 7.7% to 8.3% until 2011. This trend increase was seen in the

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first part of the period (2001 to 2004: relative increase of 6.9%) then showed a plateau in
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Doucet et al.
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the later part (2004 to 2011). Since 2004, a relative decrease of 6.0% in men whereas a

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relative increase of 5.8% was observed in women. For the overall period, age-

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standardized prevalence was higher in men compared to women but this increase

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seems to be borne by women, Figure 2 B.

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Such as incidence rate, the age-specific prevalence increased with age. Similar pattern

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were observed between men and women despite a higher prevalence in men compared

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to women in 2011 (beyond 65 years old) and in 2001 (beyond 55 years old), Figure 2 C.

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All-cause mortality

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Overall, the age-standardized all-cause mortality rates decreased from 29.4 to 22.5 per

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1000 in 2001 to 2011 (Figure 3 A) and this decline was statistically significant in men

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and in women, Table 3. In addition, the all-cause mortality rates were higher in COPD

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compared to individual without COPD.

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In 2011, the age-specific all-cause mortality rates beyond 45 years old were higher in

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men than women in all age groups and this observation was also true for the period of

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2001 (p 0.01), Figure 3 B.

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Age- period-cohort model for incidence trends

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The graphical representations were not shown because the results didnt reveal

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convincing visual interpretation.

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The age and period effects by sex are presented in figure 4 A. With no surprise, the risk

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of developing COPD was rising with age progression in both sexes. The relative risk was

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higher in men compare to women in age groups of 65 years and older. For the period
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Doucet et al.
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effect, a similar pattern between men and women was observed. The relative risk of

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developing the disease slowly diminished until the end of the observational period.

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The cohort effect realized by the median polish method analysis was presented for men

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in figures 4 B and for women in figure 4 C. Residuals values obtained from median

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polish method were similar in birth cohorts before 1949-51 in both sexes. A systematic

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deviation of residuals from zero not statistically significant, suggests a bit positive cohort

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effects in men in birth cohorts 1961-63 until 1970-72. A more important cohort effect was

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found in women by positive mean residuals in 1952-54 to 1967-69 birth cohorts. An

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increase to a significant peak of values in 1964-66 follow by a drop in 1967-69 that reach

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zero was observed.

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In addition to the median polish, the Holford method (figures 4 D and E) confirms that

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the cohort effect seen in women was similar to the age effect. The important change in

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the second-order effects around 1964-66 suggests a cohort effect in women born during

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this specific period. Therefore, in men the Holford method shows a less important cohort

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than age effect but the variability observed in the recent cohorts seems to identify a

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weak cohort effect as found in median polish method.

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Prevalence of comorbidities

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Age-standardized prevalence of seven comorbidities in COPD and rate ratios for each

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chronic disease is presented by sexes, in Figure 5 A and B respectively. The co-

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occurrence of chronic diseases prevalence in both sexes was frequent in individuals with

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COPD. Asthma, osteoporosis and mood and anxiety troubles were more prevalent in

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women with COPD (p 0.01) while diabetes, ischemic heart diseases and heart failure
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Doucet et al.
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were more prevalent in men with COPD (p 0.01). The co-occurrence of hypertension

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was equivalent in both sexes. Excess of co-occurrence of chronic diseases in individuals

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with COPD was found in both sexes. The prevalence ratios of diabetes, hypertension,

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ischemic heart diseases and heart failure were more marked in women than men (p

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0.01).

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Doucet et al.
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DISCUSSION

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For the last decade, an overall increase in COPD prevalence along with a decrease of

225

incidence and all-cause mortality was reported in Quebec. Over time, all age-

226

standardized trends were higher in men compared to women. Despite higher rates, the

227

number of incident and prevalent cases of COPD in women exceeds men since 2004.

228

The curves analysis by age-group showed in incidence and all-cause mortality a

229

downshift for both sexes overtime. This signified that all age-groups presented lower

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rate in 2011. However, this downshift in time was more marked in incidence. Further

231

analysis on incidence trends shows the presence of a cohort effect in younger women.

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Altogether, these results support an increase of the burden of COPD that was mostly

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borne by women in the last decade.

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Relationship between incidence prevalence and mortality

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The interrelation between incidence, prevalence and mortality in COPD is complex by

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the presence of different pattern overtime between sexes. This relationship could be

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figure in epidemiology by the representation of a bathtub (18). First, the measure of

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incidence is the flow of water into the tub. The reduction of COPD incidence rates

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overtime suggests that combined efforts in public health to reduce cigarette smoking

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rates, have begun to affect the number of new cases diagnoses with the disease. Over

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the past fifty years, the decrease of the prevalence of cigarette smoking is report in

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North America (19). In Canada, the peak of prevalence smoking in men was

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hypothetically identified before 1950 while in women the peak occurred around mid-

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1960s (19). The time gap between sexes in habit and cessation of cigarette smoking,

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could explain the different pattern observed. Therefore, the number of incident cases in
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Doucet et al.
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women exceeds men overtime and the decline of rates in women was less marked in all

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age-groups than men in 2011. This observation may support a link between incidence

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and cigarette smoking patterns.

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250

Secondly, the prevalence pool, figure by the amount of water fill in the bathtub, is also

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influence by the outflow down the drain represent in this study by mortality data. Since

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cause of death by COPD is largely underestimate (12, 20), and trends are declining as

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well as all cause mortality in COPD but at lower rate, the measure of all-cause of

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mortality was used to understand this relationship with prevalence. In this study, all-

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cause mortality trends decrease overtime and this was true in all age-groups. In

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addition, the pattern of all-cause mortality was similar in men and in women in contrast

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to incidence curves where less down shift in women than in men overtime.

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Incidence in COPD influence by a period and cohort effect

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Age-period-cohort analysis showed a period effect in both sexes. The relative risk

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decline suggests that COPD of different generation were all affected during the period

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analyzed. A plausible explanation of this observation could be attributing to the impact of

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the setting out of tobacco control policies establish in Canada in the 80s on the disease

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incidence. Concurrently, the decline in other chronic diseases incidence with high risk

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factor related to cigarette smoking, such has lung cancer in men (21) could reinforce this

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hypothesis. Indeed, the changes in medical diagnosis practice or other risk factor related

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to COPD until 2000 may have contribute to our observation with probably less impact

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than tobacco control policies.

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Doucet et al.
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In addition to the period effect, a cohort effect was identified in women. The birth cohort

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factor affects individuals that are born within the same years. The analysis demonstrates

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an elevated relative risk of incidence in cohorts of women born between 1952 and 1967.

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Despite an overall decline of incidence trend in women in time, the diagnosis of COPD in

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women belonging to the most recent cohorts was higher. These results support previous

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observations made with our surveillance system, that age-specific incidence and

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prevalence trends in women age beyond 55 years old were higher than men for the

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overall period. However, these founding in younger groups were not consistent in other

276

age groups. In addition to our study, elevate incidence and prevalence rates in younger

277

age categories of women was also found in other countries (22, 23). These authors

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explain their finding by different smoking habit between gender and maybe between

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younger cohorts of COPD women than other generations of COPD. In Japanese COPD

280

population, an age-period-cohort analysis performed on mortality rate observed also

281

changes in cohort effect. They conclude that cigarette consumption and smoking

282

prevalence variations overtime explain differences in sexes (22).

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Comorbidity prevalence in COPD

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Co-occurrence of chronic disease is now well recognized in the trajectory of the COPD

285

disease. In women with COPD, asthma, osteoporosis and mood and anxiety disorders

286

were more prevalent. In addition, rate ratios showed an excess of heart failure, ischemic

287

heart diseases and diabetes in women than men. In support to other studies (2, 3, 24),

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the presence of comorbidities were highly prevalent in COPD. Furthermore, women

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presented different pattern of comorbidity than men and these differences should be

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considered in the estimation of the burden.

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Doucet et al.
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Limits

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The definition case used for COPD surveillance contains limits. The modest specificity

293

and predict positive value of the health administrative data definition case lead to the

294

presence of false positive. Despite a probable overestimate of the prevalence, the

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overall prevalence estimated in 2011 is consistent with prevalence found in other

296

Canadian population-based data sources that identify the diagnoses of COPD based on

297

spirometry measures (5, 6, 9). Comparison between sources of data, have highlighted

298

that our estimates may included predominantly moderate to severe COPD with a lesser

299

captured of the milder cases, which could underestimate the overall prevalence found

300

with administrative data (9). In this study, estimates measured are dependant of the

301

diagnose record on physician billing and is an image of the clinical practice. Since

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COPD is under diagnosed by physician, the true COPD prevalence in clinical practice is

303

probably also underestimated. Consequently, estimates produce by administrative data

304

give a population portrait of individual who interact with health care system.

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The age-period-cohort model lead to certain limits such as the model itself may not

306

identify the cause of the effect observed. Finally, our relatively short observation period

307

could have had limited the estimation of the burden and the analysis for age-period-

308

cohort. However, all hypotheses put forward with this kind of analysis need to be

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confirmed in time.

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Doucet et al.
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CONCLUSIONS

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Over the last decade, prevalence rates of diagnosed COPD increased while incidence

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and all-cause mortality rates decreased. The burden of COPD has risen over time and is

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mostly associated to women. An estimation of the last decade has identified women

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younger than 65 years old as a group at risk for healthcare planning. Public health and

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the health system jointly should target this at risk group in smoking cessation, in

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screening and managing the early stage of COPD disease in order to reduce the

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increase of COPD burden.

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Doucet et al.
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ACKNOWLEDGEMENTS

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The authors acknowledge the contribution of Ernest Lo for is methodological advices on

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the manuscript. This study was supported by the Institut national de sant publique du Qubec,

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the Ministre de la Sant et des Services sociaux du Qubec and the Public Health Agency of

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Canada

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AUTHOR CONTRIBUTIONS

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MD performed the literature review. The INSPQ team (MD, LR and DH) have participated in the

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development of the surveillance results and analysis. All authors collectively drafted the

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manuscript. All authors approved the version of the manuscript that has been submitted. MD is

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its guarantor.

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CONFLICT OF INTEREST:

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Authors have no conflict of interest to declare regarding this work.

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334

ETHICS OF HUMAN AND ANIMAL EXPERIMENTS:

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The creation of the linked health administrative data used for surveillance of chronic

336

diseases in Quebec was approved by Government agencies in legal possession of the

337

databases, the public health ethics committee and the Commission daccs

338

linformation du Qubec.

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Doucet et al.
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TABLES

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Table 1
Comorbidities

ICD - 9

ICD-10

Physician Visit
Requirement

Hospital Discharge
Requirement

Asthma

493

J45-46

2 visits or more within

any 2 year period
during study for asthma

1 discharge during
study with asthma any
diagnostic field

Diabetes

250

E10-E14

2 visits or more within

any 2 year period
during study for
diabetes

1 discharge during
study with diabetes
any diagnostic field

Hypertension

401-405

I10-I13,
I15

2 visits or more within

any 2 year period
during study for
hypertension

1 discharge during
study with
hypertension any
diagnostic field

Chronic Heart
Diseases

428

I50

2 visits or more within

any 1 year period
during
study
for
Chronic Heart Disease

1 discharge during
study with Chronic
Heart Disease any
diagnostic field

Ischemic Heart
Diseases

410-414

I20-I25

2 visits or more within

any 1 year period
during
study
for
Ischemic Heart Disease

1 discharge with any

diagnostic field or 1
treatment code1 for
Ischemic Heart
Disease during study

Osteoporosis

733

M80M81

1 visit during the study 1

discharge
with
for osteoporosis ever
osteoporosis in any
diagnostic field ever

Mood or Anxiety
Disorder

296, 300, F30-F39,

311
F40-F48,
F68

1 visit during the study

for mood disorder or
anxiety disorder in one
year (has to re-qualify
every year).

1 discharge during the

study for mood
disorder or anxiety
disorder in any
diagnostic field in one
year (has to re-qualify
every year).

342
1

CCADTC : 48.02, 48.03, 48.11-48.19 / CCI : 1.IJ.50, 1.IJ.57.GQ, 1.IJ.54, 1.IJ.76

20

Doucet et al.
343

Table 2

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Incidence

Both sex

Males

Females

Segment

APC
(%)

95 %CI

APC
(%)

95 %CI

APC
(%)

95 %CI

2001-06

-6.9*

-10.4 to -3.4

-7.8*

-10.9 to -4.7

-3.4*

-10.3 to -2.1

2006-11

-1.8

-5.8 to 2.3

-2.9

-6.4 to 0.7

-1.1

-5.7 to 3.9

35 years +

345
346

*Joinpoint analysis show statistically significant segment, p 0.05.

347

APC : annual percentage of change

348

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Doucet et al.
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Table 3

350
Mortality

With COPD
(35 years +)

Both sex

Males

Females

Segment

APC
(%)

95 %CI

APC
(%)

95 %CI

APC
(%)

95 %CI

2001-11

-2.9*

-3.5 to -2.3

*-3.1

-3.7 to -2.6

*-2.4

-3.1 to -1.7

351
352

*Joinpoint analysis show statistically significant segment, p 0.05.

353

APC : annual percentage of change

354
355

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Doucet et al.
356

FIGURES

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Figure 1

358
359
360
361

Title : COPD incidence

A. Number of incidence diagnosed COPD cases, 35 years and older, by sex, Quebec,
2001-2011
25 000

Incidence cases

20 000

15 000
Males
Females

10 000

5 000

0
2001 2002 2003 2004

2005

362

2006

2007

2008

2009

2010

2011

Fiscal Year

363
364
365

B. Age-standardized COPD incidence rates, 35 years and older, by sex, Quebec, 20012011
Total

16

Males

Females

14.2

Incidence Rate, per 1000

14
12
10

10.7
7.6

8
6

6.5

4
2
0
2001

366

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Fiscal Year

23

Doucet et al.
367

C. Age-specific COPD incidence rates, by sex, Quebec, 2001 compare to 2011 period
Males - 2001

Males - 2011

Females - 2001

Females - 2011

70

Incidence Rate, per 1000

60
50
40
30
20
10
0
35-44

368

45-54

55-64

65-74

75-84

85+

Age group, years

369

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Doucet et al.
370

Figure 2

371
372
373
374

Title : COPD prevalence

A. Number of prevalent diagnosed COPD cases, 35 years and older, by sex, Quebec,
2001-2011
250 000

Prevalent cases

200 000

150 000
Males
Females

100 000

50 000

0
2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Fiscal Year

375
376
377

B. Age-standardized COPD prevalence, 35 years and older, by sex, Quebec, 2001-20011

Total
10

Males

Females

9.0

8.7

Prevalence, per 100

8
8.0

7
6

6.9

5
4
3
2
1
0
2001

378

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Fiscal Year

379
380
25

Doucet et al.
381
382

C. Age-specific COPD prevalence, by sex, Quebec, 2001 compare to 2011 period

Males - 2001

Males - 2011

Females - 2001

Females - 2011

40
35

Prevance, per 100

30
25
20
15
10
5
0
35-44

383
384
385
386
387

45-54

55-64
65-74
Age group, years

75-84

85+

388

26

Doucet et al.
389

Figure 3

390
391

Title : COPD All-cause mortality

392
393

A. Age-standardized all-cause mortality rates among individuals aged 35 years and older
with diagnosed COPD to those without diagnosed COPD, by sex, Quebec, 2001-2011
40
34.3
35

Mortality rates, per 1000

30
25.8
25

Total with COPD

24.4

Males with COPD

20
Females with COPD
19.5
15

Total Without COPD

12.0
9.2

10
5

Males without COPD

Females without COPD

8.2
6.5

0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Fiscal Year

394
395
396
397

B. Age-specific COPD all-cause mortality rates, by sex, Quebec, 2001 compare to 2011
period
Males - 2001

Males - 2011

Females - 2001

Females - 2011

Mortality Rate, per 1000

250

200

150

100

50

0
35-44

398

45-54

55-64
65-74
Age group, years

75-84

85+

399
400
27

Doucet et al.
401

Figure 4

402
403

Age-Period-Cohort effects in COPD incidence rates for males and females

404

A. Age and period effects, by sex

405
5

Relative risk

Males
0.2

Females

406

Period

83-85

80-82

77-79

74-76

71-73

68-70

65-67

62-64

59-61

56-58

53-55

50-52

47-49

44-46

41-43

38-40

35-37

2009-2011

2006-2008

2003-2005

2000-2002

0.04

Age

407
408

28

415
1967-69
1970-72

1970-72

1946-48

1943-45

1940-42

1937-39

1934-36

1931-33

1928-30

1967-69

-0.06
1964-66

-0.04

1964-66

-0.02
1961-63

1961-63

0.02
1958-60

0.04

1958-60

0.06
1955-57

0.08

1955-57

414
1952-54

C. Cohort effect in females (Median Polish method)

1952-54

412
1949-51

Birth Cohort

1949-51

1946-48

411

1943-45

1940-42

1937-39

1934-36

1931-33

1928-30

413
z1925-27

z1922-24

Residual Values

409

z1925-27

z1922-24

Residual Values

Doucet et al.

B. Cohort effect in men (Median Polish method)

410
0.08

0.06

0.04

0.02

-0.02

-0.04

-0.06

Birth Cohort

416

417

29

424
Age

-0.1
1949-1951

1946-1948

1943-1945

1940-1942

1937-1939

1934-1936

1931-1933

1928-1930

z1925-1927

z1922-1924

83-85

80-82

77-79

74-76

71-73

68-70

65-67

62-64

59-61

56-58

53-55

50-52

47-49

44-46

41-43

38-40

1970-1972

-0.08
1967-1969

-0.06

1970-1972

-0.04
1964-1966

1967-1969

-0.02
1961-1963

0.02

1964-1966

0.04
1958-1960

0.06

1961-1963

0.08
1955-1957

423

1958-1960

E. Cohort effect in females (Holford method)

1952-1954

421

1955-1957

Cohort

1952-1954

1949-1951

1946-1948

Age

1943-1945

1940-1942

1937-1939

1934-1936

1931-1933

1928-1930

z1925-1927

z1922-1924

83-85

80-82

77-79

74-76

71-73

68-70

65-67

62-64

420

59-61

56-58

53-55

50-52

47-49

44-46

422

41-43

35-37

Effect Estimate

418

38-40

35-37

Effect Estimate

Doucet et al.

D. Cohort effect in men (Holford method)

419
0.08

0.06

0.04

0.02

-0.02

-0.04

-0.06

-0.08

-0.1

Cohort

425

30

Doucet et al.
426

Figure 5

427
428

Comorbidities prevalence

429
430

A. Age standardize comorbidities prevalence among COPD, 35 years and older, by sexes
for the period 2011
40
35

Prevalence, per 100

30
25
20
15

Males

10

Females

5
0

431
432
433
434

B. Rate ratios of age standardize comorbidities rate among individuals with and without
COPD 35 years and older, by sexes for the period 2011

Asthma
Diabetes
Hypertension
Ishemic heart diseases
Males
Heart failiure

Females

Osteoporosis
Mood and anxiety
0

Rate ratio (with COPD / Without COPD)

435
436

31

Doucet et al.
437

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